Life-sustaining Treatment Research Articles

Variation in US Hospital Policies Addressing Decisions to Withhold and Withdraw Life Sustaining Treatment

Variation in US Hospital Policies Addressing Decisions to Withhold and Withdraw Life Sustaining Treatment

Evaluating feedback reports to support documentation of veterans’ care preferences in home based primary care

BackgroundTo evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented.MethodsWe distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation.ResultsLST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports.ConclusionsFeedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.

Racial and Ethnic Disparities in Serious Illness Conversation Quality during the COVID-19 Pandemic

ContextThe COVID-19 pandemic disproportionately impacted non-Hispanic Black and Hispanic patients. However, little is known about the quality of serious illness communication in these communities during this time. ObjectiveWe aimed to determine whether racial and ethnic disparities manifested in serious illness conversations during the pandemic. MethodsThis was a retrospective, observational, cohort study of adult patients with a documented serious illness conversation from March 2020 to April 2021. Serious illness conversation documentation quality was assessed by counting the median number (IQR) of conversation domains and their elements included in the documentation. Domains included (1) values and goals, (2) prognosis and illness understanding, (3) end-of-life care planning, and (4) life-sustaining treatment preferences. A multivariable ordinal logistic regression analysis was conducted to assess associations between differences in serious illness documentation quality with patient race and ethnicity. ResultsAmong 291 patients, 149 (51.2%) were non-Hispanic White; 81 (27.8%) were non-Hispanic Black; and 61 (21.0%) were Hispanic patients. Non-Hispanic Black patients were associated with fewer domains (OR 0.46 [95% CI 0.25, 0.84]; P=.01) included in their serious illness conversation documentation compared to non-Hispanic White patients. Both non-Hispanic Black (OR 0.35 [95% CI 0.20, 0.62]; P<.001) and Hispanic patients (OR 0.29 [95% CI 0.14, 0.58]; P<.001) were associated with fewer elements in the values and goals domain compared to non-Hispanic White patients in their serious illness documentation. ConclusionDuring the COVID-19 pandemic, serious illness conversation documentation among non-Hispanic Black and Hispanic patients was less comprehensive compared to non-Hispanic White patients.

Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care

ContextRecent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. ObjectivesTo better understand decision-making regarding mechanical ventilation in people living with dementia. MethodsThis was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. ResultsThe median age was 78 years (IQR 71–86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. ConclusionFuture efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.

Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review

Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review Abstract: Background: Withdrawal of life sustaining measures is a common mode of treatment prior to the death of a critically ill child and has implications for all involved. The perspective of nurses has not yet been considered in this context. Aim: How do nurses experience the termination of life-sustaining measures in the paediatric intensive care unit? What is their role in this process? Methods: An integrative review was conducted to answer the research question. The literature search was performed in October 2022 in the CINAHL, Medline and PsycINFO databases. Results: Three qualitative and five quantitative studies were included. The confrontation with emotions, uncertainties in the decision-making process, challenges and conflicts in collaboration, in interacting with those involved and in the provision of care determine the experience of nurses during treatment withdrawal. The nurses as involved in the decision-making process and representative of interests are influenced by intrarole conflicts. Conclusion: Nursing professionals need support to cope with their experiences in the context of treatment withdrawal in children. In addition to surveying the type and scope of support measures, interprofessional guidelines must be developed when life-sustaining measures are withdrawn. This includes future research to specify the role of nurses in treatment withdrawal and includes, for example, the description of specific tasks, necessary skills or the extent of involvement in decision-making.

A JURIDICAL REVIEW OF INFORMED CONSENT BASED ON LAW NUMBER 17 OF 2023 CONCERNING HEALTH AS A REPLACEMENT FOR LAW NUMBER 36 OF 2009

In contemporary times, with the increasing legal awareness among the general public, the aspect of legal protection has become a focal point in the healthcare legal framework in Indonesia. The Law Number 17 of 2023 concerning Health, replacing Law Number 36 of 2009, illustrates significant changes in the healthcare legal structure in Indonesia. One of the primaries focuses in the implementation of this law is informed consent, which serves as a legal protection tool for patients. Therefore, this study aims to explore the regulation of informed consent in Law Number 17 of 2023 and its implementation among healthcare professionals or facilities. This research employs a normative juridical analysis method by examining the document of the Republic of Indonesia Law Number 17 of 2023 concerning Health, which replaces Law Number 36 of 2009 concerning Health. Legal reviews are conducted by referring to various legal sources and expert opinions. The research findings indicate that Law Number 17 of 2023 establishes a stronger foundation compared to the previous law for the implementation of informed consent. Informed consent is emphasized as both a medical duty and a patient's right, with an emphasis on providing comprehensive information. These changes reflect responses to the unequal access to healthcare services and the need to strengthen the national healthcare system, particularly in the context of emergencies, extraordinary events, or outbreaks. The study notes that there is still a need for adaptation and thorough understanding from healthcare professionals and facilities to maintain a balance between patient rights and the public health interest. Further issues to be addressed include aspects of informed consent that are not elaborated in detail in this new law, such as medical expansion procedures and decisions regarding life-sustaining treatment cessation or postponement. Keywords: Healthcare Law; Informed Consent; Legal protection.

Aligning goals with care: Advance directives in older adults with implantable cardioverter-defibrillators.

Patients ≥80 with implantable cardioverter-defibrillators (ICDs) have high rates of hospitalization and mortality, yet few have documented advance directives. We sought to determine the prevalence of advance directives in adults ≥80 years with ICDs, focusing on those with frailty and cognitive impairment. Prospective cohort study (July 2016-May 2019) in an electrophysiology clinic. Presence of advance directives (health care proxies [HCP] and living wills [LW], or medical orders for life-sustaining treatment [MOLST]) was determined by medical record review. Frailty and cognitive impairment were screened using 4-m gait speed and Mini-Cog. 77 Veterans were evaluated. Mean age 84 years, 100% male, 70% frail. Overall, 52 (68%) had an HCP and 37 (48%) had a LW/MOLST. Of 67 with cognitive testing, 36% were impaired. HCP documentation was similar among frail and non-frail (69%vs. 65%). LW/MOLST was more prevalent among frail versus non-frail (52%vs. 39%). There was no difference in HCP documentation by cognitive status (67%). A LW/MOLST was more frequent for cognitively impaired versus non-impaired (50%vs. 42%). Among 19 Veterans who were frail and cognitively impaired, 14 (74%) had an HCP and 11 (58%) had a LW/MOLST. Most Veterans had a documented advance directive, but a significant minority did not. Simple frailty and cognitive screening tools can rapidly identify patients for whom discussion of advance directives is especially important.

The Gap in Attitudes Toward Withholding and Withdrawing Life-Sustaining Treatment Between Japanese Physicians and Citizens

Background According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians’ and citizens’ attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment. Methods Ten vignette cases were developed. A web-based questionnaire was administered to 457 citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment. Results In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient’s family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient’s request than mechanical ventilation (49%). Conclusions A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings.

What Are the Real Issues in Providing Extracorporeal Membrane Oxygenation (ECMO) Support: A Survey.

By using a novel survey our study aimed to assess the challenges ECMO and Critical Care (CC) teams face when initiating and managing patient's ECMO support. A qualitative survey-based observational study was performed of members of 2 Critical Care Medicine organizations involved in decision-making around the practice of Extracorporeal Membrane Oxygenation (ECMO). The range of exploratory questions covered ethical principles of informed consent, autonomy and goals of care discussions, beneficence, non-maleficence (offering life-sustaining treatments in end-of-life care), and justice (insurance-related limitations of treatment). Questions also covered pragmatic practice and quality improvement areas, such as exploring whether palliative care or ethics teams were involved in such decision-making. 305 members received the survey links, and a total of 61 completed surveys were received, for an overall response rate of 20% among all eligible members. Only 70% of the participants who manage ECMO patients are involved in the ECMO initiation decision process. The majority do not involve Ethics or Palliative care at the initial ECMO initiation decision step. Of the ethical and moral dilemmas reported, the majority revolved around 1. Prognostication of patients receiving VV and VA ECMO support, 2. Lack of knowledge of patient's wishes and goals, 3. Disconnect between expectations of families and outcomes and 4. Staff moral distress around when to stop ECMO in case of futility. Our survey highlights areas of distress and dilemma which have been stressed before in the initiation, management, and outcomes of ECMO patients, however with the increasing use of this modality of cardiopulmonary mechanical support being offered, the survey results can offer a guidance using sound ethical principles.

Life-Sustaining Treatment and Advance Care Documentation among Chinese American ICU Decedents

ContextDespite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. ObjectivesTo compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. MethodsIn this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. ResultsWe identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99–3.40) and DNI completion (OR 1.81; 95%CI, 1.07–1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55–1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03–41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). ConclusionsDuring terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

343 Regional Variability in the Management of Aneurysmal Subarachnoid Hemorrhage for Black Patients: An Analysis of Treatment Patterns, Outcomes, and End-of-life Care.

INTRODUCTION: Disparities in the care of Black Americans with aneurysmal subarachnoid hemorrhage (aSAH) have been described. However, regional variations for Black patients with aSAH have yet to be delineated, particularly in end-of-life care. METHODS: We analyzed aSAH data from the Nationwide Inpatient Sample (NIS) from 2016-2020. Controlling for covariates, multivariate logistic regression models were used to assess U.S. Census region differences between Black and White patients in treatment, adverse outcomes, mortality, use of palliative care as well as do not resuscitate (DNR) and of life-sustaining interventions (mechanical ventilation, tracheostomy, gastrostomy, blood transfusion). RESULTS: Black patients in the East-North Central (ENC) division were less likely to have inpatient morality following aSAH (OR 0.68, 95% CI 055 – 0.83, p &lt;0.001), yet more likely to have tracheostomy (OR 1.83, 95% CI 1.39 - 2.49, p &lt; 0.001) and gastrostomy (OR 1.66, 95% CI 1.31 - 2.11, p &lt; 0.001) tube placement than the national average. Furthermore, Black patients in the ENC were less likely to have palliative care (OR 0.42, 95% CI 0.22 - 0.80, p = 0.008) This trend continued in the West South-Central (WSC) division for tracheostomy (OR 1.86, 95% CI 1.29 - 2.66, p = 0.001), gastrostomy (OR 1.95, 95% CI 1.44 - 2.63, p &lt; 0.001), and palliative care (OR .67, 95% CI 0.51 - 0.87, p = 0.003). CONCLUSIONS: Geographic variations exist in the treatment of Black patients with aSAH. Nationally and regionally Black patients have lower mortality rates than White patients, due in part to disparities in end-of-life care. Black patients receive more life-sustaining interventions, and less palliative care and DNR; this is most evident in the ENC and WSC regions. Paradoxically, regions with more Black residents fare worse.

785 Variability in Withdrawal of Life Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury: An Analysis of 510 North American Trauma Centers

INTRODUCTION: Withdrawal of life sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex with a paucity of standardized guidelines to inform practice patterns. We hypothesized presence of variability in WLST decision-making across centers, which could have important implications for equitable trauma care provision. METHODS: This retrospective study utilized data from adult severe TBI patients treated at trauma centers participating in the Trauma Quality Improvement Program between 2017-2020. Multivariable hierarchical logistic regression was used to adjust for patient, injury and hospital attributes influencing WLST. Residual between-center variability was characterized using the median odds ratio. Disparate WLST practices were further assessed by ranking centers' tendencies for WLST and assessing mortality between quartiles. RESULTS: We identified a total of 85511 subjects with severe TBI treated across 510 trauma centers, of which 20,300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, white race, treatment in a non-profit trauma center or self-pay/ Medicare insurance status (compared to private insurance). Black race was associated with reduced tendency for WLST. Higher severity intracranial and extracranial injuries also increased likelihood for WLST.After adjustment for patient and hospital attributes, the median odds ratio was 1.44 (1.40-1.48 95%CI), suggesting substantial residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was a 1.37 (1.30-1.42 95%CI) increased adjusted odds of mortality between fourth versus first quartile centers. CONCLUSIONS: We highlighted the presence of disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a strong need for examination of center-level factors contributing to heterogenous WLST practices to ultimately improve equity of care provision for severe TBI patients.

Controlled donation after circulatory death in post-cardiac arrest patients: Estimates from a large registry

BackgroundControlled donation after circulatory death (cDCD) in post-anoxic brain injury is a valuable source of organs that is still underused in some countries. We assessed the number of potential cDCD donors after out-of-hospital cardiac arrest (OHCA) in Paris and its suburbs and extrapolated the results to the French population. MethodsUsing the large regional registry of the Great Paris area, we prospectively included all consecutive adults with OHCA with a stable return of spontaneous circulation (ROSC) who ultimately died in the intensive care unit (ICU) after withdrawal of life-sustaining treatments (WLST) due to post anoxic brain injury. The primary endpoint was potential for organ donation by cDCD in this population. The number of potential cDCD donors was calculated and extrapolated to the entire French population. ResultsBetween 2011 and 2018, 4638 patients with stable ROSC were admitted to ICUs after OHCA, and 3170 died in ICU, of which 1034 died after WLST due to post-anoxic brain injury. When considering French criteria, 421/1034 patients (41%) would have been potential cDCD donors (55 patients per year in a 4.67 million population). After standardization for age and sex, the potential for cDCD was 515 (95% CI 471–560) patients per year in France corresponding to an annual incidence of 1.18 per 100 000 inhabitants per year. ConclusionsOrgan donation by cDCD after cardiac arrest could provide a large pool of donors in France.

Bleeding Control Protections Within US Good Samaritan Laws.

In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.

Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study

BackgroundClinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches.MethodsThis was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality.ResultsThere were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987–19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351–60.298) were both found to be independent predictors of hospital mortality on multivariable analysis.ConclusionsDifferences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.

Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data.

The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.

Measuring patients’ medical treatment preferences in advance care planning: development and validation of the Treat-Me-ACP instrument – a secondary analysis of a cluster-randomized controlled trial

BackgroundAdvance Care Planning interventions should be evaluated as broadly as possible to gain a holistic understanding of the Advance Care Planning process. However, validated early stage outcome instruments are lacking. Therefore, the Treatment-Preference-Measure-Advance Care Planning (Treat-Me-ACP) instrument was developed and validated as part of the cluster-randomized controlled trial STADPLAN (Study on Advance Care Planning in care-dependent community-dwelling older persons) to assess the effects of Advance Care Planning interventions on patients’ medical treatment preferences.MethodsThe design of Treat-Me-ACP is based on the Emanuel Medical Directive and the Life Support Preferences Questionnaires. Using a multi-stage team approach a preliminary version of the Treat-Me-ACP was developed and pre-tested. The pre-tested instrument consists of one global medical care goal-item, five hypothetical scenarios with five hypothetical treatments, and one how would you feel-item within each scenario. A total of five scenario preference scores and five treatment preference scores can be formed. This version was subsequently applied to a subsample of the STADPLAN project (n = 80) to assess patient’s preferences at baseline (T0) and at 12-month follow-up (T2). The further validation steps were based on this subsample and included: (1) acceptance by using completion rate and frequencies of missing data, (2) internal consistency by using Cronbach’s α to test whether it was possible to create preference scores by scenario and treatment, (3) concurrent validation examining the association between the global medical care goal-item and the preference scores and the association between the how would you feel-items and the scenario preference scores, and (4) responsiveness of the instrument to changes in preferences for life-sustaining treatments by comparing preference scores from T0 to T2 between study groups.ResultsAcceptance of the instrument was high. Results of concurrent validation indicate that the five scenarios represent the global medical care goal well. The preference scores showed an average tendency for decreasing preferences for life-sustaining treatments across all scales for the intervention group during study follow-up.ConclusionsThe Treat-Me-ACP can be used to evaluate the dynamics of patients’ medical treatment preferences in Advance Care Planning. It has been validated for care-dependent community-dwelling older persons and can be used as an additional outcome measure in evaluating the effectiveness of ACP interventions.Trial registrationGerman Clinical Trials Register: DRKS00016886 on 04/06/2019.

O169: The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation

Abstract Background Agonal times can vary between organ donors after circulatory death (DCD) following withdrawal of treatment, which leads to variable warm ischaemic damage to pancreas grafts. Currently there is little evidence supporting procurement team standdown times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following DCD transplantation. Methods Data were extracted from the UK transplant registry from 2014 to 2022. TTD was defined as withdrawal of life-sustaining treatment to donor asystole; asystolic time was the time from asystole to aortic perfusion. Predictors of graft loss were fitted into a Cox proportional hazards model. Adjusted restricted cubic spline (RCS) models were generated to further delineate the relationship between TTD and outcome. Statistical significance was set at P&amp;lt;0.05. Results 375 DCD simultaneous kidney-pancreas transplant recipients were included. Median TTD was 13-minutes (IQR 10 to 16-minutes), median asystolic time was 13-minutes (IQR 11 to 15-minutes). Increasing TTD was not associated with poorer graft survival (aHR 0.98, 95% CI 0.68-1.41, P=0.901). Increasing asystolic time was significantly associated with worse graft survival in the TTD model (aHR 2.51, 95%CI 1.16-5.43, P=0.020). RCS modelling confirmed there was no relationship between TTD and graft survival, however a non-linear relationship was demonstrated between asystolic time and graft survival. Conclusion We found no evidence that TTD impacts pancreas graft survival in DCD SPK transplantation, however increasing asystolic time was significant predictors of graft loss. Procurement teams should attempt to minimise asystolic time to reduce ischaemic injury to the pancreas graft.

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Factors affecting nurses' attitude toward withdrawal of life-sustaining treatment for children

PurposeThe purpose of study was to investigate factors affecting nurses' attitudes toward withdrawal of life-sustaining treatment in children. Design and methodsThis descriptive survey study included 167 nurses working at children's hospitals or children's wards. Data were collected through a structured self-administered survey in November 2022. Data were analyzed using descriptive analysis, t-test, ANOVA, the Dunnett's T3 test, Pearson's correlation coefficient, and multiple linear regression. ResultsAttitude toward withdrawal of life-sustaining treatment in children showed a significant positive correlation with knowledge of life-sustaining treatment decision-making (r = 0.38, p < .001) and meaning as a subcategory of moral sensitivity (r = 0.21, p 0.008). The factors affecting attitude toward withdrawal of life-sustaining treatment in children were knowledge of life-sustaining treatment decision-making (β =0.31, p < .001) and meaning (β = 0.18, p = .015). This model showed a 21.0% explanation of attitude toward withdrawal of life-sustaining treatment in children. ConclusionsDeveloping an effective educational program designed to improve nurses' knowledge and attitude toward life-sustaining treatment decision-making is necessary. Practice implicationsIt may have a positive influence on attitudes toward withdrawal of life-sustaining treatment in children by improving child nurses' knowledge about life-sustaining treatment decision-making and moral sensitivity.